The nurse should intervene and explain to the AP that this statement constitutes which of the following torts?
- A. Assault
- B. Battery
- C. False imprisonment
- D. Negligence
Correct Answer: A
Rationale: The correct answer is A: Assault. Assault is the intentional act causing the apprehension of harmful or offensive contact. In this scenario, the statement made by the AP creates fear or apprehension of harm, even though no physical contact has occurred yet.
Choice B (Battery) involves actual physical contact, which is not present here. Choice C (False imprisonment) involves restricting someone's movement, not applicable in this situation. Choice D (Negligence) is the failure to exercise reasonable care, which is not the case here. The correct answer, assault, best fits the scenario described.
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Which of the following actions should the nurse take?
- A. Assist the caregiver to arrange a daycare program for the client.
- B. Advise the caregiver to take time for themselves when possible.
- C. Encourage the caregiver to focus on the positive aspects of caregiving.
- D. Remind the caregiver that their loved one depends on them completely.
Correct Answer: A
Rationale: The correct answer is A because arranging a daycare program for the client allows the caregiver to have a break and attend to their own needs. This promotes self-care, prevents burnout, and ensures the well-being of both the caregiver and the client. Choice B, advising the caregiver to take time for themselves, is not as effective as it doesn't provide a concrete solution like arranging daycare. Choice C, encouraging the caregiver to focus on the positive aspects, may be helpful but does not address the need for respite. Choice D, reminding the caregiver of their loved one depending on them, may increase guilt and stress.
Which laboratory test should the nurse report?
- A. INR
- B. Prothrombin time (PT)
- C. Activated partial thromboplastin time (aPTT)
- D. Platelet count
- E. Hemoglobin and hematocrit levels
Correct Answer: A
Rationale: The correct answer is A: INR. The nurse should report the INR (International Normalized Ratio) test because it specifically measures the effectiveness of anticoagulant therapy like warfarin. A high INR indicates a higher risk of bleeding, while a low INR indicates a higher risk of clotting. Reporting the INR can help healthcare providers adjust medication dosage to maintain optimal therapeutic levels.
Incorrect choices:
B: Prothrombin time (PT) is related to INR but is less specific for monitoring anticoagulant therapy.
C: Activated partial thromboplastin time (aPTT) is used to monitor heparin therapy, not warfarin.
D: Platelet count assesses the number of platelets, not the effectiveness of anticoagulant therapy.
E: Hemoglobin and hematocrit levels assess blood volume and oxygen-carrying capacity, not anticoagulant therapy.
Select the 5 complications the client is at risk for.
- A. Hypertension
- B. Hypocalcemia
- C. Calcium resorption
- D. Urinary stasis
- E. Contractures
- F. Atelectasis
- G. Diarrhea
Correct Answer: C,D,E,F,H
Rationale: Immobility increases risks of urinary stasis, contractures, atelectasis, and pressure injuries.
Which action should the nurse take when working with the interpreter?
- A. Speak in a normal voice at a natural pace.
- B. Use medical jargon to ensure accuracy.
- C. Speak directly to the interpreter instead of the client.
- D. Ask the client to respond only with 'yes' or 'no' answers.
Correct Answer: A
Rationale: The correct answer is A: Speak in a normal voice at a natural pace. This is important because speaking clearly and at a natural pace allows the interpreter to accurately convey the message without missing any information. Using a normal voice also helps maintain a respectful and professional tone during communication.
Choice B is incorrect because using medical jargon may confuse the interpreter and lead to miscommunication. Choice C is incorrect as the nurse should always address the client directly to establish trust and rapport. Choice D is incorrect as it restricts the client's ability to express themselves fully.
The nurse is assessing the client. Which of the following findings indicate an improvement in the client's condition? Select all that apply.
- A. The client engages in quiet activities in their room
- B. The client slept 5 hr. the previous night
- C. The client consumes 8 oz of high-calorie fluids each hour
- D. The client takes 2 short naps during the day
- E. The client appears to listen to unseen others.
Correct Answer: A,B,C,D
Rationale: Improved behaviors include engaging in quiet activities, sleeping adequately, consuming fluids, and napping appropriately. Listening to unseen others indicates ongoing psychosis.